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    Published by the World Health Organization in collaboration with the World Heart Federation and the World Stroke Organization. Global Atlason cardiovasculardisease prevention and control Published by the World Health Organization in collaboration with the World Heart Federation and the World Stroke Organization. ISBN 978 92 4 156437 3 Global Atlas on cardiovascular disease prevention and control Global Atlason cardiovascular disease prevention and control CVDs 20 Avenue Appia CH-1211 Geneva 27 Switzerland www.who.int/Joint Publication of the World Health Organization the World Heart Federation and the World Stroke Organization Global Atlason cardiovasculardisease prevention and controlJoint Publication of the World Health Organization the World Heart Federation and the World Stroke Organization ISBN 978 92 4 256419 8 9 789242 564198 Global Atlas on cardiovascular disease prevention and control Global Atlason cardiovascular disease prevention and control CVDs 20 Avenue Appia CH-1211 Geneva 27 Switzerland www.who.int/ International efforts aimed at poverty reduction will be derailed if the rapidly growing global cardiovascular disease burden is ignored. In the absence of prevention strategies, increasing numbers of people will succumb to heart attacks and strokes due to continuing exposure to risk factors. Millions of premature deaths due to cardiovascular disease can be prevented by scaling up the implementation of affordable, high impact interventions, which already exist.Global Atlas on cardiovascular disease prevention and control Published by the World Health Organization in collaboration with the World Heart Federation and the World Stroke Organization . editors: Shanthi Mendis, Pekka Puska and Bo NorrvingWHO library Cataloguing-in-Publication Data Global atlas on cardiovascular disease prevention and control 2011/ edited by Shanthi Mendis …[et al]. 1.Cardiovascular diseases - prevention and control. 2.Cardiovascular diseases - epidemiology. 3.Cardiovascular diseases - economics. 4.Cardiovascular diseases - mortality. 5.Health promotion. 6.Atlases. I.Mendis, Shanthi. II.Puska, Pekka. III.Norrving, B. IV.World Health Organization. V.World Heart Federation. VI.World Stroke Organization. ISBN 978 92 4 156437 3 (NLM classification: WG 120) Suggested citation: Global Atlas on Cardiovascular Disease Prevention and Control. Mendis S, Puska P , Norrving B editors. World Health Organization, Geneva 2011. This document was developed by the World Health Organization (Shanthi Mendis) in collaboration with the World Heart Federation (Pekka Puska) and the World Stroke Organization (Bo Norrving) Contributions were made by A. Alwan, T. Armstrong, D. Bettcher, T. Boerma, F. Branca, J. C.Y. Ho, C. Mathers, R. Martinez, V. Poznyak, G. Roglic, L. Riley, E. d`Espaignet, G. Stevens, K.Taubert and G. Xuereb. Others who provided assistance in various ways in the compilation of this document include A. Ayinla, X. Bi, F. Besson, L. Bhatti, A. Enyioma, N. Christenson, F. Lubega, P . Nordet, M. Osekre-Amey and J. Tarel. © World Health Organization 2011 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www. who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press through the WHO web site (http://www.who.int/about/ licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in FranceIII Global Atlas on Cardiovascular Diseases Prevention and Control Table of contents Abbreviations and Measurements V Foreword VI Section A – Cardiovascular diseases (CVDs) due to atherosclerosis 1 1. What are cardiovascular diseases (CVDs)? 2 2. Death and disability due to CVDs (heart attacks and strokes) 8 3. The underlying pathology of heart attacks and strokes 14 4. Evidence for prevention of heart attacks and strokes 16 5. Reducing cardiovascular risk to prevent heart attacks and strokes 18 6. Tobacco: The totally avoidable risk factor of CVDs 26 7. Physical inactivity: A preventable risk factor of CVDs 28 8. Harmful use of alcohol: A preventable risk factor of CVDs 30 9. Unhealthy diet: A preventable risk factor of CVDs 32 10. Obesity: A risk factor of CVDs 36 11. Raised blood pressure (hypertension): A major risk factor of CVDs 38 12. Raised blood sugar (diabetes): A major risk factor of CVDs 40 13. Raised blood cholesterol: A major risk factor of CVDs 42 14. Social determinants and CVDs 44 15. Risk factors take root in the womb, childhood and youth 46 16. Heart attacks and strokes in women 48 17. Other determinants of CVDs: Ageing, globalization and urbanization 50 18. Inequities and CVDs 54 Section B – Other cardiovascular diseases 57 19. Cardiac arrhythmia 58 20. Congenital heart disease 60 21. Rheumatic heart disease: A neglected heart disease of the poor 62 22. Chagas disease (American trypanosomiasis): A neglected disease of the poor 66IV Global Atlas on Cardiovascular Diseases Prevention and Control Section C – Prevention and control of CVDs: Policies, strategies and interventions 69 23. Prevention and control of CVDs: How do we know what works? 70 24. Prevention and control of CVDs: The need for integrated and complimentary strategies 72 25. Prevention and control of CVDs: Health in All Policies 74 26. Prevention and control of CVDs: The need for a national NCD policy framework 76 27. Policies and strategies for tobacco control 78 28. Policies and strategies to facilitate healthy eating 80 29. Policies and strategies to facilitate physical activity 84 30. Policies and strategies to address the harmful use of alcohol 88 31. Individual interventions for prevention and control of CVDs 92 32. Role of primary health care in prevention and control of CVDs 94 33. Best buys for cardiovascular disease (CVD) prevention and control 96 34. Bridging the implementation gap for prevention and control of CVDs 100 35. Monitoring CVDs 102 36. Social mobilization for prevention and control of CVDs 104 37. Prevention and control of CVDs and socioeconomic development 106 38. Generating resources for CVD prevention and control 108 39. CVD prevention and control: Why it should not be ignored any longer? 110 40. CVD prevention and control : Vision, roadmap and a landmark event 114 World Health Organization, World Heart Federation and World Stroke Organization 118 References 119 List of figures 127 References for figures 131 Annexes 133 Annex I – World Health Assembly resolution A64/61 134 Annex II – Moscow Declaration 136 Annex III – Regional Declarations on NCDs 139 Annex IV – Contact information 144 Annex V – Age-standardized death rates per 100,000 both sexes by cause and Member State, 2008 (1) 148 Index 153V Global Atlas on Cardiovascular Diseases Prevention and Control Abbreviations AIDS acquired immunodeficiency syndrome BMI body mass index CVD cardiovascular disease DALY disability-adjusted life year FCTC Framework Convention on Tobacco Control GDP gross domestic product GNP gross national product G20 Group of 20 countries HDL cholesterol high-density lipoprotein cholesterol HIV human immunodeficiency virus ISH International Society of Hypertension LDL cholesterol low-density lipoprotein cholesterol LMIC low- and middle-income country MDG Millennium Development Goal NCD noncommunicable disease NGO nongovernmental organization UN United Nations USA United States of America WHA World Health Assembly WHO World Health Organization WHO Global NCD Action Plan WHO 2008–2013 Action Plan for the Global Strategy for Prevention and Control of Noncommunicable Diseases WHO NCD Research Agenda WHO Prioritized Research Agenda for Prevention and Control of Major Noncommunicable Diseases YLD years living with disability Measurements dl decilitre g gram kg kilogram l litre M/m metre mg milligram mmHg millimetre of mercury mmol millimoleVI Global Atlas on Cardiovascular Diseases Prevention and Control Cardiovascular diseases (CVDs) remain the biggest cause of deaths worldwide. More than 17 million people died from CVDs in 2008. More than 3 million of these deaths occurred before the age of 60 and could have largely been prevented. The percentage of premature deaths from CVDs ranges from 4% in high-income countries to 42% in low-income countries, leading to growing inequalities in the occurrence and outcome of CVDs between countries and populations. There are also new dimensions to this alarming situation. Over the past two decades, deaths from CVDs have been declining in high-income countries, but have increased at an astonishingly fast rate in low- and middle-income countries (LMIC). CVDs are largely preventable. Both population wide measures and improved access to individual health care interventions can result in a major reduction in the health and socioeconomic burden caused by these diseases and their risk factors. These interven- tions, which are evidence based and cost effective, are described as best buys in the Global Status Report on Noncommunicable Diseases (NCDs) 2010. At present, public health services in developing countries are overstretched by increasing demands to cope with heart disease, stroke, cancer, diabetes and chronic respiratory disease. At the same time, health care systems in many LMIC are let down by a model based on hospital care focused on the treatment of diseas- es, often centred around high-technology hospitals that provide extensive treatment for only a small minority of citizens. Hospitals consume huge amounts of resources, and health ministries may spend more than half their budgets on treatment services which depend on hospitals. As a result, a large proportion of people with high cardiovascular risk remain undiagnosed, and even those diagnosed have insufficient access to treatment at the primary health-care level; while evidence suggests two-thirds of prema- ture deaths due to NCDs including CVDs can be prevented by primary prevention and another one-third by improving health systems to respond more effectively and equitably to the health- care needs of people with NCDs. Two new developments have led to this report at this juncture. The first development is the growing international awareness that premature deaths from CVDs and other NCDs reduce pro- ductivity, curtails economic growth, and pose a significant social challenge in most countries. The second development is that there is now unequivocal evidence that “best buy“ interventions to reduce the toll of premature deaths due to CVDs and other NCDs are workable solutions and that they are excellent econom- ic investments -- including in the poorest countries. As the magnitude of CVDs continue to accelerate globally, the pressing need for increased awareness and for stronger and more focused international and country responses is increasingly recognized. This atlas on cardiovascular disease prevention and control is part of the response to this need. It documents the magnitude of the problem, using global cardiovascular mortal- ity and morbidity data. It demonstrates the inequities in access to protection, exposure to risk, and access to care as the cause of major inequalities between countries and populations in the occurrence and outcome of CVDs. It also highlights the causes responsible for the declining cardiovascular mortality in devel- oped countries, and sends the message that, to break this cycle of growing inequalities, we must use this knowledge to benefit people in all countries. Addressing CVDs require concrete and sustained action in three areas which represent the key components of any global or na- tional strategy; surveillance and monitoring, prevention and re- duction of risk factors, and improved management and health care through early detection and timely treatment. Actions should include setting national goals and targets and measuring results, advancing multisectoral partnerships and health-in-all- policies approaches, strengthening health systems and primary health care, and developing the appropriate national capacity and institutional arrangements to manage NCD programmes. Halting premature deaths from CVDs and other NCDs will also require global solidarity and broad alliances that go beyond national, cultural and ethnic boundaries. Eleven years since the landmark World Health Assembly endorsed the Global Strategy for the Prevention and Control of NCDs to reduce the toll of pre- mature deaths due to CVDs and other NCDs. Heads of State and Government will come together to address the prevention and control of NCDs worldwide at the 2011 High-level Meeting of the United Nations General Assembly on the Prevention and Control of NCDs between 19-20 September 2011 in New York. This is the second time in the history of the United Nations that the General Assembly will meet on a health issue with major socio-economic impact. National leaders are expected to adopt a concise action- oriented outcome document that will shape the international agenda for years to come. The opportunity provided by the High-level Meeting is unprecedent- ed. By ensuring that the response to CVDs is placed at the forefront of international efforts to promote development and protect health, we will be achieving a more balanced distribution of the benefits of globalization and, in turn, reinforce the broader scope of human se- curity. And this gives me an occasion for great optimism. Dr Ala Alwan Assistant Director
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